Postoperatively, patients wore a below-the-knee cast that held the ankle in 20° of plantar flexion, and non-weight-bearing walking was continued for 2 weeks. At 3 weeks postoperatively, the cast was removed and an ankle-foot orthosis with 3 heel wedges that held the ankle in 20° of plantar flexion was applied. Partial weight-bearing walking and range-of-motion exercises were initiated. One heel wedge was removed each week. Patients were encouraged to bear weight on the involved limb as soon as they felt comfortable and to gradually progress to full weight-bearing. At 6 weeks postoperatively, the orthosis was removed. Double-heel-rise exercises were allowed at 7 weeks. Sports activities were encouraged at 4 to 5 months postoperatively.
Differences between preoperative and final postoperative measurements were analyzed using the Wilcoxon signed rank test. The Wilcoxon-Mann-Whitney test was used to compare the maximum calf circumference between the ruptured and nonruptured sides at the time of the latest follow-up. Significance was defined as p < 0.05. Kappa statistics were used to analyze the interobserver reliability using SPSS, version 22.0 (IBM).
At the time of the latest follow-up, none of the patients exhibited any difficulty in walking or climbing stairs. Twenty-eight patients were pain-free and 2 patients reported occasional mild calf pain. All 14 athletes had returned to their pre-injury level of sports participation. The 3 competitive athletes had full return to sports (i.e., played in a game at their pre-injury level) at 5 to 6 months postoperatively, and the 11 recreational athletes fully returned to sports by 12 months postoperatively. The mean plantar flexion angle of the involved ankle significantly increased postoperatively (p = 0.0049). The mean dorsiflexion angle of the involved ankle significantly decreased postoperatively (p = 0.009). The mean calf circumference of the involved leg significantly increased postoperatively (p = 0.0087). The mean difference in circumference between the involved and uninvolved calves was significantly higher preoperatively than that at the time of the latest follow-up (p = 0.0135). At the most recent follow-up examination, all except 2 patients could perform a single-limb heel rise. The mean AOFAS score was 82.8 points preoperatively and 98.1 points at the time of the most recent follow-up examination (Table II). The mean ATRS at the time of the latest follow-up was 92.0 points (range, 80 to 100 points).
The only postoperative complication was delayed wound-healing in 1 case, which healed within 4 weeks postoperatively without antibiotic treatment. There were no cases of infection, deep-vein thrombosis, skin necrosis, or rerupture.
Preoperative and Postoperative MRI
The kappa value for the interobserver reliability of MRI was 0.83 for tendon contour and 0.90 for a signal change. According to the system of Landis and Koch33, these values corresponded to an almost perfect level of agreement. On preoperative T2-weighted images, fusiform-shaped tendon thickening and diffuse intratendinous high-signal alterations in the tendons were seen in 22 patients (Fig. 3-A), but these patients had homogeneous low-signal alterations in the tendons on MRI at 6 months postoperatively (Fig. 3-B). Tendon thinning was seen in the remaining 8 patients. Diffuse intratendinous high-signal alterations were seen preoperatively in 6 of these 8 patients (Fig. 4-A), but fusiform-shaped tendon thickening and homogeneous low-signal alterations were seen in the tendons on MRI at 6 months postoperatively (Fig. 4-B). Homogeneous low-signal alterations in the tendons were seen in 2 patients (Fig. 5-A) preoperatively, but both fusiform-shaped tendon thickening and homogeneous low-signal alterations were seen in the tendons on MRI at 6 months postoperatively (Fig. 5-B).
In all specimens, scar tissue located between the tendon stumps consisted of dense and thick collagen fibers with vessels. Obvious degenerative changes, such as tendolipomatosis, mucoid degeneration, or vascular changes34, were not observed in any specimen. In 9 patients, scar tissue between the tendon stumps contained dense collagen fibers running parallel along the tendon axis with rows of fibroblasts lying between the bundles of collagen. However, the bundles of collagen fibers were thinner, and more fibroblasts were seen, compared with the intact tendon (Fig. 6-A). In the remaining 21 specimens, the scar tissue contained dense collagen fibers with highly cellular fibrovascular material, but the fiber bundles were not oriented along the axis of the tendon (Fig. 6-B). In the 3 patients whose duration from injury to the time of the surgical procedure was <12 weeks, less dense and thinner collagen fibers not oriented along the axis of the tendon with highly cellular fibrovascular material were seen.
Wounds can heal by primary union (first intention) or secondary union (second intention); second intention healing involves more extensive scarring and wound contraction35. Repair by connective tissue deposition involves angiogenesis, migration and proliferation of fibroblasts, collagen synthesis, and connective tissue remodeling35. After Achilles tendon rupture, Achilles tendon healing that occurs following immobilization with nonsurgical treatment corresponds to second intention healing. However, delayed or neglected Achilles tendon ruptures do not progress to natural second intention healing. During wound-healing, a granulating wound that is assisted in its healing by an operative procedure, is changed from healing by second intention to healing by third intention36. Similarly, in the present study, we performed delayed primary suturing for these delayed or neglected Achilles tendon ruptures, creating healing by third intention.
We treated 30 consecutive patients with chronic Achilles tendon rupture using a direct repair procedure. The postoperative scores were 98.1 points for the AOFAS score and 92.0 points for the ATRS, both of which were greater than previously reported scores for chronic Achilles tendon rupture, which ranged from 85 to 96.5 points for the AOFAS and 83 to 91 points for the ATRS6,12,13,17-19,25. There were no cases of rerupture, and all 14 athletes had returned to their pre-injury level of sports participation. Thus, the clinical outcomes of our operative method were at least comparable with previously reported outcomes for chronic Achilles tendon rupture. Moreover, our technique was associated with a lower rate (3%) of postoperative complications than those previously reported, which ranged from 4 to 45%6,7,11,12,14,17,18,20. All except 2 patients could perform a single-limb heel rise postoperatively. We think that shortening of the elongated scar tissue restored the length of the Achilles tendon.
A few reports have been published on the histologic findings of scar tissue between tendon stumps in chronic Achilles tendon ruptures25,26,28. Lee et al.25 showed that the interposed scar tissue was composed of thick collagen fibers that ran in parallel along the tendon axis. In our study, interposed scar tissue contained dense collagen fibers with arteries, veins, and capillaries. In 9 patients, interposed tissue contained dense collagen fibers running parallel along the tendon axis. In the remaining 21 specimens, the scar tissue contained dense collagen fibers with highly cellular fibrovascular tissue not oriented along the axis of the tendon. Histologic findings have clearly indicated that the scar tissue has the capacity to form tendon-like tissue. In the present study, 27 patients were >12 weeks post-injury, so the interposed tissue in these patients showed the healing of the fairly mature tendon; however, the bundles of collagen fibers were thinner than the intact tendon. The histology results suggest that it is possible to use interposed healing tissue to repair chronic Achilles tendon rupture.
Postoperative MRI findings indicated good tendon healing of the reconstructed Achilles tendon in all patients. Preoperatively, thin elongated scar tissue was observed in 8 patients (Figs. 4-A and 5-A). Even in these cases, we performed direct repair using interposed scar tissue (Fig. 7), and postoperative MRI findings showed fusiform-shaped tendon thickening and homogeneous low-signal alterations in the tendons (Figs. 4-B and 5-B). We think that resection of the middle part of the scar tissue led to the migration of the fibroblasts from the stumps. The proliferation of fibroblasts and neovascularization followed by fibrogenesis in the repaired tendon may have increased the tendon thickness and resulted in the fusiform shape observed postoperatively. Furthermore, tension on the suture site due to early functional rehabilitation may have aligned the bundles of collagen fibers parallel to one another along the axis of the tendon, thus increasing its mechanical strength27,37. We believe that our operative method restored the length of the elongated scar and improved the tendon strength based on the postoperative tendon thickening and good arrangement of the bundles of collagen fibers.
This study had some limitations. First, to our knowledge, the psychometric properties of the AOFAS scoring system, including its validity and reliability, have never been examined. However, there is still value in comparing our results with those of other published studies. Second, we used the Japanese version of the ATRS questionnaire. The validity and reliability of the English and Turkish versions of the ATRS questionnaire have been demonstrated30,31; however, the Japanese version has not been validated.
In conclusion, shortening of the tissue between the 2 tendon ends that included healing scar and direct repair of healing tendon without allograft or autograft can be effective for the treatment of delayed or neglected Achilles tendon rupture.
Investigation performed at the Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
Disclosure: There were no external funding sources. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article.
1. Barnes MJ, Hardy AE. Delayed reconstruction of the calcaneal tendon. J Bone Joint Surg Br. 1986 ;68(1):121–4.
2. Bosworth DM. Repair of defects in the tendo Achillis. J Bone Joint Surg Am. 1956 ;38(1):111–4.
3. Bugg EI Jr, Boyd BM. Repair of neglected rupture or laceration of the Achilles tendon. Clin Orthop Relat Res. 1968 ;56:73–5.
4. Gabel S, Manoli A 2nd. Neglected rupture of the Achilles tendon. Foot Ankle Int. 1994 ;15(9):512–7.
5. Kissel CG, Blacklidge DK, Crowley DL. Repair of neglected Achilles tendon ruptures—procedure and functional results. J Foot Ankle Surg. 1994 ;33(1):46–52.
6. Lee DK. Achilles tendon repair with acellular tissue graft augmentation in neglected ruptures. J Foot Ankle Surg. 2007 ;46(6):451–5.
7. Lee YS, Lin CC, Chen CN, Chen SH, Liao WY, Huang CR. Reconstruction for neglected Achilles tendon rupture: the modified Bosworth technique. Orthopedics. 2005 ;28(7):647–50.
8. Leslie HD, Edwards WH. Neglected ruptures of the Achilles tendon. Foot Ankle Clin. 2005 ;10(2):357–70.
9. Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am. 1999 ;81(7):1019–36.
10. Maffulli N, Ajis A. Management of chronic ruptures of the Achilles tendon. J Bone Joint Surg Am. 2008 ;90(6):1348–60.
11. Maffulli N, Spiezia F, Testa V, Capasso G, Longo UG, Denaro V. Free gracilis tendon graft for reconstruction of chronic tears of the Achilles tendon. J Bone Joint Surg Am. 2012 ;94(10):906–10.
12. Maffulli N, Loppini M, Longo UG, Maffulli GD, Denaro V. Minimally invasive reconstruction of chronic Achilles tendon ruptures using the ipsilateral free semitendinosus tendon graft and interference screw fixation. Am J Sports Med. 2013 ;41(5):1100–7. Epub 2013 Mar 6.
13. Maffulli N, Oliva F, Costa V, Del Buono A. The management of chronic rupture of the Achilles tendon: minimally invasive peroneus brevis tendon transfer. Bone Joint J. 2015 ;97(3):353–7.
14. Mann RA, Holmes GB Jr, Seale KS, Collins DN. Chronic rupture of the Achilles tendon: a new technique of repair. J Bone Joint Surg Am. 1991 ;73(2):214–9.
15. Miskulin M, Miškulin A, Klobučar H, Kuvalja S. Neglected rupture of the Achilles tendon treated with peroneus brevis transfer: a functional assessment of 5 cases. J Foot Ankle Surg. 2005 ;44(1):49–56.
16. Dumbre Patil SS, Dumbre Patil VS, Basa VR, Dombale AB. Semitendinosus tendon autograft for reconstruction of large defects in chronic Achilles tendon ruptures. Foot Ankle Int. 2014 ;35(7):699–705. Epub 2014 Apr 10.
17. Rahm S, Spross C, Gerber F, Farshad M, Buck FM, Espinosa N. Operative treatment of chronic irreparable Achilles tendon ruptures with large flexor hallucis longus tendon transfers. Foot Ankle Int. 2013 ;34(8):1100–10. Epub 2013 Apr 26.
18. Sarzaeem MM, Lemraski MMB, Safdari F. Chronic Achilles tendon rupture reconstruction using a free semitendinosus tendon graft transfer. Knee Surg Sports Traumatol Arthrosc. 2012 ;20(7):1386–91. Epub 2011 Oct 29.
19. El Shazly O, Abou El Soud MM, El Mikkawy DME, El Ganzoury I, Ibrahim AM. Endoscopic-assisted Achilles tendon reconstruction with free hamstring tendon autograft for chronic rupture of Achilles tendon: clinical and isokinetic evaluation. Arthroscopy. 2014 ;30(5):622–8.
20. El Shewy MT, El Barbary HM, Abdel-Ghani H. Repair of chronic rupture of the Achilles tendon using 2 intratendinous flaps from the proximal gastrocnemius-soleus complex. Am J Sports Med. 2009 ;37(8):1570–7. Epub 2009 Jun 11.
21. Us AK, Bilgin SS, Aydin T, Mergen E. Repair of neglected Achilles tendon ruptures: procedures and functional results. Arch Orthop Trauma Surg. 1997;116(6-7):408–11.
22. Wapner KL, Pavlock GS, Hecht PJ, Naselli F, Walther R. Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer. Foot Ankle. 1993 ;14(8):443–9.
23. Wegrzyn J, Luciani JF, Philippot R, Brunet-Guedj E, Moyen B, Besse JL. Chronic Achilles tendon rupture reconstruction using a modified flexor hallucis longus transfer. Int Orthop. 2010 ;34(8):1187–92. Epub 2009 Aug 21.
24. Myerson MS. Achilles tendon ruptures. Instr Course Lect. 1999;48:219–30.
25. Lee KB, Park YH, Yoon TR, Chung JY. Reconstruction of neglected Achilles tendon rupture using the flexor hallucis tendon. Knee Surg Sports Traumatol Arthrosc. 2009 ;17(3):316–20. Epub 2008 Dec 16.
26. Porter DA, Mannarino FP, Snead D, Gabel SJ, Ostrowski M. Primary repair without augmentation for early neglected Achilles tendon ruptures in the recreational athlete. Foot Ankle Int. 1997 ;18(9):557–64.
27. Yasuda T, Kinoshita M, Abe M, Shibayama Y. Unfavorable effect of knee immobilization on Achilles tendon healing in rabbits. Acta Orthop Scand. 2000 ;71(1):69–73.
28. Yasuda T, Kinoshita M, Okuda R. Reconstruction of chronic Achilles tendon rupture with the use of interposed tissue between the stumps. Am J Sports Med. 2007 ;35(4):582–8. Epub 2007 Feb 9.
29. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994 ;15(7):349–53.
30. Nilsson-Helander K, Thomeé R, Silbernagel KG, Thomeé P, Faxén E, Eriksson BI, Karlsson J. The Achilles tendon Total Rupture Score (ATRS): development and validation. Am J Sports Med. 2007 ;35(3):421–6. Epub 2006 Dec 7.
31. Kaya Mutlu E, Celik D, Kiliçoglu Ö, Ozdincler AR, Nilsson-Helander K. The Turkish version of the Achilles tendon Total Rupture Score: cross-cultural adaptation, reliability and validity. Knee Surg Sports Traumatol Arthrosc. 2015 ;23(8):2427–32. Epub 2014 May 10.
32. Mandelbaum BR, Myerson MS, Forster R. Achilles tendon ruptures. A new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med. 1995 ;23(4):392–5.
33. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977 ;33(1):159–74.
34. Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991 ;73(10):1507–25.
35. Mitchell RN. Inflammation and repair. In: Kumar V, Abbas AK, Aster JC, editors. Robbins basic pathology. 9th ed. Philadelphia: Elsevier Saunders; 2013. p 29–73.
36. Bate JT. Second and third intention healing of finger amputations. A salvage procedure. Clin Orthop Relat Res. 1966 ;47:151–5.
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37. Becker H, Diegelmann RF. The influence of tension on intrinsic tendon fibroplasias. Orthop Rev. 1984;13(3):65–71.